Health inspection·May 22, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure oxygen was administered according to physician orders. This affected one resident (Resident #2) out of three residents reviewed for oxygen. The facility census was 70. Residents Affected - Few Findings include: Review of the medical record for Resident #2 revealed an admission date of 01/18/24 with diagnoses including pleural effusion, long term use of anticoagulants, atrial fibrillation, anemia, moderate protein-calorie malnutrition, hyperlipidemia, heart failure, essential (primary) hypertension, type two diabetes mellitus, osteoarthritis, cataract extraction status, stage four chronic kidney disease, and neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition. The MDS further revealed Resident #2 had a history of respiratory failure and was receiving oxygen therapy. Review of the care plan dated 04/19/24 revealed Resident #2 was at risk for respiratory distress related to congestive heart failure (CHF), pleural effusion, history of COVID-19, and respiratory failure. Interventions included administering oxygen as ordered. Review of the physician orders revealed an order dated 04/05/24 for oxygen to run at two liters per minute via nasal cannula (NC) continuously every shift for shortness of breath (SOB). Review of the progress notes revealed a respiratory therapy assessment dated [DATE]. Further review of the note revealed Resident #2 was on four liters of oxygen at the time of the assessment on 04/12/24 and the respiratory therapist recommendation was to place an order for oxygen weaning. Observation on 05/22/24 at 11:10 A.M. of Resident #2 revealed she was asleep with oxygen running via NC through an oxygen concentrator set at four liters. Interview on 05/22/24 at 12:15 P.M. with Resident #2 confirmed she was on four liters of oxygen. Another observation at this time revealed the oxygen setting on the oxygen concentrator was four liters per minute. Observation on 05/22/24 at 4:05 P.M. of Resident #2 in the activity room revealed her oxygen was running via NC from a portable oxygen tank set to four liters per minute. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366447 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concord Village Skilled Nursing & Rehabilitation 10955 Capital Parkway Concord, OH 44077 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)